Provider First Line Business Practice Location Address:
1203 S ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHENANDOAH
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51601-2221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-246-4627
Provider Business Practice Location Address Fax Number:
712-246-7357
Provider Enumeration Date:
09/23/2005